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UNDERSTANDING THE U.S. HEALTH SERVICES SYSTEM Fourth Edition

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AUPHA/HAP Editorial Board for Graduate Studies Timothy D. McBride, PhD, Chair Washington University in St. Louis John Baker, PhD University of Arkansas for Medical Sciences Simone Cummings, PhD Washington University Connie J. Evashwick, ScD, FACHE St. Louis University Sherril B. Gelmon, DrPH, FACHE Portland State University Thomas E. Getzen, PhD Temple University Diane M. Howard, PhD, FACHE Rush University Christy H. Lemak, PhD University of Michigan John M. Lowe III, PhD Simmons College Lydia Middleton AUPHA Dawn Oetjen, PhD University of Central Florida Mark Pauly, PhD University of Pennsylvania Bernardo Ramirez, MD University of Central Florida Andrew T. Sumner, ScD Georgia State University Andrea W. White, PhD Medical University of South Carolina Lesly Wilson, PhD University of South Carolina

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UNDERSTANDING THE U.S. HEALTH SERVICES SYSTEM Fourth Edition

Phoe be L inds ey B a rton

Health Administration Press, Chicago, Illinois AUPHA Press, Washington, DC

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Your board, staff, or clients may also benefit from this book’s insight. For more information on quantity discounts, contact the Health Administration Press Marketing Manager at (312) 424–9470. This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The statements and opinions contained in this book are strictly those of the author and do not represent the official positions of the American College of Healthcare Executives, the Foundation of the American College of Healthcare Executives, or the Association of University Programs in Health Administration. Copyright © 2010 by the Foundation of the American College of Healthcare Executives. Printed in the United States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without written permission of the publisher. 14  13  12  11  10   5  4  3  2  1

Library of Congress Cataloging-in-Publication Data Barton, Phoebe Lindsey.   Understanding the U.S. health services system / Phoebe Lindsey Barton. — 4th ed.    p. ; cm.   Includes bibliographical references and index.   ISBN 978-1-56793-338-3 (alk. paper)   1.  Medical care—United States.  2.  Medical policy—United States.  3.  Medical economics—United States.  I.  Title.   [DNLM:  1.  Health Services—United States.  2.  Delivery of Health Care—United States.  3.  Economics, Medical—United States.  4.  Health Policy—United States.  W 84 AA1 B293u 2010]   RA395.A3B27  2010   362.10973—dc22 2009033085 The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1984. ∞ ™ Acquisitions editor: Janet Davis; Project manager: Eduard B. Avis; Cover designer: Trisha Lartz. Take Cover Design; Layout: BookComp Found an error or typo? We want to know! Please e-mail it to [email protected], and put “Book Error” in the subject line. For photocopying and copyright information, please contact Copyright Clearance Center at www.copyright.com or at (978) 750–8400. Health Administration Press Association of University Programs A division of the Foundation   in Health Administration   of the American College of 2000 North 14th Street   Healthcare Executives Suite 780 One North Franklin Street, Arlington, VA 22201 Suite 1700 (703) 894–0940 Chicago, IL 60606–3529 (312) 424–2800

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In loving memory of Doctors Milton and Ruth Roemer and their seminal work on health care systems.

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brief Contents

List of Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxix Part I Introduction

1

Introduction to the U.S. Health Services System . . . . . . . . . . . 3



2 An Overview of the U.S. Health Services System and Its Users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11



3

Access to Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Part II System Organization

4

Organization of the U.S. Health Services System . . . . . . . . . . 77

Part III System Management

5

Management of the U.S. Health Services System . . . . . . . . . . 97

Part IV Economic Support

6 Health Insurance: The Major Financing Mechanism for the U.S. Health Services System . . . . . . . . . . . . . . . . . . . 109



7

Financing the U.S. Health Services System . . . . . . . . . . . . . . 175

Part V Resource Production

8

The Health Services Workforce . . . . . . . . . . . . . . . . . . . . . . . 213



9

Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251



10 Biomedical Research, Health Services Technology, and Technology Assessment . . . . . . . . . . . . . . . . . . . . . . . . . 279

vii

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viii

Brief Contents

Part VI

The Delivery System



11

Overview of the U.S. Health Services Delivery System . . . . . 305



12

Health Promotion and Disease Prevention . . . . . . . . . . . . . . 319



13

Primary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331



14

Secondary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339



15

Long-Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349



16

Tertiary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383



17

Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .391



18

The Care of Special Populations and Special Disorders . . . . . 399



19 The Health Services Delivery System: How Managed Care Has Influenced Delivery . . . . . . . . . . . . . . . . . . . . . . . . 415

Part VII

Measuring Outcomes of the Delivery System



20

Issues in Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449



21

Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473

Glossary of Key Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545 About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571

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Contents

List of Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxix Part I Introduction

1

Introduction to the U.S. Health Services System . . . . . . . . . . . 3 Exhibit 1.1 Types of National Health Systems . . . . . . . . . . . . . . . . 4 Overview of the U.S. Health Services System . . . . . . . . . . . . . . . . . . . 4 Exhibit 1.2 Continuum of Health Services . . . . . . . . . . . . . . . . . . . 5 The Roemer Model of a Health Services System . . . . . . . . . . . . . . . . . 5 Exhibit 1.3 National Health System: Components, Functions, and Their Interdependence . . . . . . . . . . . . . . . . . . . . 6 Organization of Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Management of a Health Services System . . . . . . . . . . . . . . . . . . . . . . 7 Production of Health Services Resources . . . . . . . . . . . . . . . . . . . . . . 8 Delivery of Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 System Values: Access, Cost and Expenditures, and Quality . . . . . . . . . 8 Organization of the Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Data on U.S. Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Aids to Understanding the Complexity of the U.S. Health Services System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10



2 An Overview of the U.S. Health Services System and its Users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 An Overview of the U.S. Health Services System . . . . . . . . . . . . . . . . 11 Distinguishing Health from Illness and Disease . . . . . . . . . . . . . . . . . 15 Exhibit 2.1 Determinants of Health . . . . . . . . . . . . . . . . . . . . . . . 16 Exhibit 2.2 U.S. Crude Birthrates and Fertility Rates . . . . . . . . . . 17 Exhibit 2.3 U.S. Life Expectancy at Birth, Age 65, and Age 75 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Exhibit 2.4 U.S. Low-Birth-Weight (